RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02012
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080829

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Mortuary Affairs Specialist) medically separated for chronic right ankle pain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “right ankle arthrosis status post subtalar coalition” and “right ankle pain secondary to…(the coalition)” conditions were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB adjudicated “chronic right ankle pain” as unfitting, rated 10%, citing application of Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.  

CI CONTENTION:  Her conditions continue to worsen and negatively impact her daily activities.  Her complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of VASRD standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:  

IPEB – Dated 20080616	VA* - ~2 Months Post-Separation 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Ankle Pain	5099-5003	10%	Right Achilles Tendinitis…	5271-5024	10%	20081114	
			Right Ankle Scar	7804	10%		
			Right Heel Bursitis	5284-5019	0%		
Other x 0 (Not In Scope)	Other x 10	
RATING: 10%	COMBINED RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20090710 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Chronic Right Ankle Pain.  The record showed that the CI, who had been a ballerina prior to service, first presented for bilateral foot numbness on 7 March 2006, 8 weeks after accession.  Her examination was unremarkable and no diagnosis was made.  She was again seen for a 4-week history of bilateral foot numbness on 3 July 2006.  She was referred to physical therapy (PT) and seen on 14 August 2006.  She reported right ankle and knee pain for several months, but that she had passed her physical fitness test in June.  Her symptoms were aggravated by activity and the wear of boots.  A slight limp was present.  She was then evaluated in podiatry and noted to have a flexion pes cavus (high arch) and issued orthotics.  An MRI on 13 September 2006 showed a subtalar coalition (an abnormal fibrous or cartilage bridge that connects the two tarsal bones [ankle bones] which normally are separate.  It can be congenital or from trauma).  She was evaluated in orthopedics on 21 February 2007 and it was noted that she had been a ballerina for 12 years, had done ok in basic, but had increased pain in advanced infantry training as she ran more.  She had noted pain previously when she was in ballet and attributed it to her activities then.  She had X-rays on 21 February 2007 of the right foot and ankle which were normal.  A bone scan showed increased uptake in the subtalar region bilaterally.  She was treated with duty limitations and PT, but her symptoms continued, primarily on the right.  A repeat MRI on 25 April 2007 showed stable findings.  On 30 August 2007, she underwent a right tarsal coalition takedown (a debridement of the fibrous union) as well as a lengthening of the Achilles tendon.  The operative report is not in evidence.  She was then rehabilitated in physical therapy and regained function, but had persistent pain with activity.  On 1 November 2007, 2 months after surgery, the CI was seen in PT and noted to have a non-antalgic gait (implying normal) with a slight effusion.  Some weakness of the ankle was noted.  Active and passive range-of-motion (ROM) measurements were identical with some reduction in dorsi-flexion (toes up).  The next month, she was referred for dietary counseling for weight control; the 67 inch CI had weighed 183 pounds at accession.  When seen in PT on 3 January 2008, she reported ankle pain when walking over 2 miles, but was able to teach dance to 6-7 year old children.  The effusion was resolved and her gait normal.  The ROM was unchanged, but her motor function near normal.  She was seen in orthopedics 2 weeks later and reported that her pain had resolved except when jogging.  She lacked full dorsiflexion compared to the left by a few degrees.  The ankle examination was otherwise unremarkable.  She was again seen in orthopedics on 15 April 2008 and reported continued pain, numbness in her right heel since the surgery, and a snapping sensation in the right ankle.  On examination, she was thought to have a possible rupture of the right calf muscle (gastrocnemius).  Some swelling was noted of the right ankle, but the ROM was full bilaterally, but painful, and the ankles stable.  The CI was seen in PT 2 days later for formal ROM measurements (below).  She reported that pain impeded her ability to walk and stand and that her ankle was stiff.  However, the examiner noted that she was able to stand from a sitting position quickly without complaint of pain and walked to the examination room with an unremarkable gait.  The ROM, which had been normal 2 days earlier, was reduced for both ankles.  The narrative summary (NARSUM) was dated 17 April 2008 and dictated by the same clinician who had seen her on 15 April 2008.  On examination, she was mildly tender over the surgical scar, a bursa (fluid filled sac to reduce friction) behind the heel bone, and Achilles tendon.  Motion was painful, but the ankle stable and the motor function now normal.  She reported decreased sensation in her heel to light touch.  At the MEB examination on 30 April 2008, the CI reported the loss of heel sensation and continued pain.  On examination, the scar was healed and the ankle without deformity.  The heel bone and Achilles tendon were tender and light touch decreased over the right heel and Achilles tendon.  Her final profile did not limit the wear of military foot wear.  The Board noted that she was noted to have a normal arch.  At the VA Compensation and Pension (C&P) examination performed on 14 November 2008, 2 months after separation, the CI reported stiffness and ongoing pain.  She could function without medications.  She could not stand for prolonged periods or wear flat shoes.  She was able to do the activities of daily living including pushing a lawn mower.  On examination, her posture and gait were normal.  The ankle scar was tender and hyper-pigmented, but otherwise the scars were unremarkable.  She did not use assistive devices other than shoe inserts and did not have an unusual shoe wear pattern.  The right ankle and both feet were tender to touch.  The ankle was stable and alignment normal.  The neurological examination was normal.  X-rays showed a normal right ankle and weight bearing X-rays showed pes planus (flat foot) bilaterally, the opposite of what had been previously diagnoses (pes cavus).  This was not otherwise found in the record including the VA C&P examination.  

The Board directed its attention to its rating recommendation based on the above evidence.  The MEB forwarded right ankle arthrosis s/p subtalar coalition s/p surgery with secondary pain to the PEB.  The PEB adjudicated chronic right ankle pain as unfitting at 10% for painful motion, coded 5099-5003 (analogous to degenerative arthritis). The VA rated three related right ankle conditions: right Achilles tendinitis, coded 5271-5024 (limited motion of the ankle-tenosynovitis), at 10%; right ankle scar, coded 7804 (scar, unstable or painful), at 10%; and right heel bursitis, 5284-5019 (other foot injuries-bursitis), at 0%.  The Board considered the evidence.  While the Achilles tendon and bursa were noted to be tender at the NARSUM, neither Achilles tendinitis nor bursitis were diagnosed, determined to fail retention standards, or considered by the MEB or PEB.  These diagnoses are therefore not in the Board’s scope of review.  Regardless, the limitation from the tendinitis and bursitis was pain and stiffness, which is also the case with the subtalar coalition.  Separate ratings are not permitted IAW VASRD §4.14 (avoidance of pyramiding).  The scar was tender, but there is no indication in the record that it interfered with duty.  The final profile did not restrict the wear of military foot wear.  Accordingly, it does not rise to the level of unfitting and is not ratable.  The Board then considered the ankle.  Motion was painful and limited on the PT and MEB examinations prior to separation.  However, the PT examiner for the MEB noted that the CI was able to rise from sitting to standing without evidence of pain and walked easily to the examination room.  These observations are not consistent with the degree of limitation in motion formally measured and the probative value of these measurements is therefore diminished.  The CI was noted to have full ROM at the final orthopedic clinical evaluation and also on the VA C&P, consistent with the normal gait observed on the MEB and C&P examinations.  Painful motion, present on some examinations, supports a 10% rating.  The Board did note that the CI was diagnosed, on different examinations, with pes cavus, pes planus, and a normal arch.  This had no bearing on the rating recommendation.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the chronic right ankle pain condition.  

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the chronic right ankle pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination. 

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140709, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX AR20160004361 (PD201402012)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA